Impact of the COVID-19 pandemic on access and use of health services by middle-aged and older Australians

Keywords: chronic disease, COVID-19, health services, mental health, population surveys, telehealth.

Over the past 2 years, the direct effects of coronavirus disease 2019 (COVID-19) on morbidity and mortality have been well established. There is also increasing evidence of the indirect impacts of the COVID-19 pandemic on health and wellbeing, partly attributed to delayed access to emergency or routine care and missed diagnoses.^1–4 Such delays may increase the risk of adverse health outcomes and affect the morbidity and mortality of individuals.^2,3 This is of particular importance in middle-aged and older people, as the risk of many diseases are known to increase with age.⁵

There is also growing concern, and emerging evidence, that vulnerable groups within society have been disproportionately affected by the indirect impacts of COVID-19.^6–10 Identification of groups that are most at risk is crucial to inform the implementation of policy and health services to minimise adverse impacts on the community and ensure that they do not translate into persisting inequalities, or an exacerbation of adverse health.

Telehealth has been recognised as a means of facilitating continued access to healthcare services during the COVID-19 pandemic while minimising the community risk of COVID-19 transmission.¹¹ Prior to the COVID-19 pandemic, telehealth was available in Australia, but remunerated in limited settings, particularly for rural and regional areas.¹² In March 2020, the Australian Government introduced a range of telehealth items into the Medicare Benefits Schedule to reduce barriers to accessing health care during the COVID-19 pandemic.¹³ There is currently little information on the use of these services, and whether service uptake was comparable across different socio-demographic groups.

The aim of this study was to examine the impact of the COVID-19 pandemic on access to healthcare services by middle-aged and older Australians, and to assess the use of telehealth services during the COVID-19 pandemic and ongoing acceptability and usefulness.

The study included data collected as part of the Sax Institute’s 45 and Up Study, which was established in 2006 to track the health and ageing of individuals aged ≥45 years living in New South Wales (NSW), Australia. Prospective participants were randomly sampled using the Services Australia Medicare enrolment database. Those aged 80+ years and living in rural and remote areas were oversampled, with a response rate of approximately 18% of those invited to participate. Baseline data were collected via postal survey between 2006 and 2009 (n = 267 153), with subsequent surveys conducted in 2012–15 (Wave 2; n = 142 548) and 2018–20 (Wave 3; n = 97 302). The surveys collected information on a broad range of health and social topics, including participants’ socio-demographic characteristics, health, lifestyle, behaviours, living situation, carer responsibilities, relationships, psychological distress, quality of life and chronic conditions.¹⁴

In July–December 2020, the Wave 3 Follow-Up Survey was posted to 85 299 study participants. In addition to the standard questionnaire, participants completed a COVID-19 Supplement, which included questions to explore the impact of the COVID-19 pandemic on health, lifestyle, access and use of health services and experiences with telehealth.¹⁵

The study outcomes included missed or delayed access to a range of health services as a result of the COVID-19 pandemic, and whether this resulted in a change in self-reported health. Health services were pre-defined in the survey (Supplementary Table S1) and did not include access to telehealth services. Use of telehealth services since January 2020, acceptability and perceived ongoing usefulness of these services were explored using separate questions. Overall physical and emotional/psychological health, physical activity, financial situation as a result of the COVID-19 pandemic and social contact were also assessed (survey details are included in Supplementary Table S1 and available online at: https://www.saxinstitute.org.au/our-work/45-up-study/questionnaires/).

Information on socio-demographic characteristics and indicators of potential vulnerability were identified from the 45 and Up Study baseline and Wave 3 survey. These included age at the time of the 2020 survey, sex, residential location and educational qualification. Postcode of residence was combined with the Accessibility/Remoteness Index of Australia¹⁶ to classify geographical location, whereas socioeconomic status was determined using the Australian Bureau of Statistics Socio-Economic Indexes for Areas (ABS SEIFA) Index of Relative Socioeconomic Disadvantage.¹⁷

Vulnerable or at-risk groups were defined as participants classified as most disadvantaged, spoke a language other than English at home, indicated that they regularly needed help with daily tasks due to long-term illness or disability, or received treatment for a range of chronic conditions in the month prior to the time of survey completion. Health conditions assessed in our study included heart disease (heart attack or angina, and other heart disease), cancer, asthma and mental health disorder (i.e. anxiety and depression). Level of psychological distress was assessed using the Kessler 10 (K10), a validated tool that scores psychological distress on a four-point scale from low to very high.¹⁸

The number and rates of participants reporting study outcomes were calculated overall and by socio-demographic characteristics and health conditions. Association of socio-demographic characteristics and health conditions with study outcomes, including missed/delayed access to health services and use of telehealth services, were assessed using multivariable logistic regression analysis. All analyses were conducted using SAS v9.4 (SAS Institute Inc.) and only those results where the P-value was <0.05 or the odds ratios with 95% confidence intervals did not include ‘one’ were considered to be statistically significant and presented in the text.

Ethics approval for this study was obtained from the University of Sydney Human Research Ethics Committee (Project Number: 2021/038), with original ethics for the 45 and Up Study from the University of NSW Human Research Ethics Committee. The research was undertaken with appropriate informed consent of participants or guardians.

In total, 45 071 (53%) participants were included in the second follow-up Wave 3 survey (excluding seven withdrawn consents) (Table 1). The sample comprised slightly more females (55.9%) than males (44.1%), with the highest proportion of participants aged between 65 and 75 years (41.1%), compared with 45–64 years (28.1%) and 75+ years (30.8%). The highest educational qualification completed was evenly distributed between ≤Year 12 (32.3%), trade/diploma (34.5%) and university (33.3%). Nearly 8% of participants had an illness or disability that required help with daily tasks, or had received treatment in the past month for cancer (3.9%), heart disease (5.0%), asthma (5.3%) and mental health issues (8.3%) (Table 1). Approximately half (51.7%) of the participants were residing in a major city, 37.4% in inner regional and 10.9% in outer regional to very remote areas (Table 1).

Table 1.  Missed or delayed access to GP, specialist and dental health services categorised by socio-demographic characteristics and health conditions.

Regarding the impact of COVID-19 pandemic, 82% of participants reported their overall health and 70% reported their emotional/psychological health to be the same. However, 9% said their overall health and 26% their emotional/psychological health was worse. This was more likely among people aged 45−64 years, who have a disability, asthma or mental health condition. Compared to 12 months ago, 28% reported less time spent engaged in physical activity, 25% increased time spent watching TV and 10% more time sleeping. Two-thirds (67%) of participants indicated their financial situation was the same, 4% reported it was better and 28% reported it had worsened. Change in social contact was high, with 92% reporting reduced personal contact, mostly due to health concerns for themselves (76%) or others (72%).

Almost half (42.2%) the participants reported that they had missed or delayed access to health care due to COVID-19, mostly for dental services (26.1%), visits to general practitioners (GPs) (16.3%) and specialists (12.6%). Those with the highest rates of missed or delayed access to these services included participants with moderate to very high levels of psychological distress, those who had treatment in the past month for health conditions (especially mental health) and those with a disability/illness requiring help (Table 1). Missed/delayed access to other services including hospital or aged care, blood tests, psychological care, vaccination, cancer screening, and prescription and non-prescription medication ranged between 1.5 and 4.9% (Supplementary Table S2).

Missed/delayed visits to specialists was more likely to be reported by females and participants from non-English-speaking backgrounds, with disability/illness, living in outer regional and remote areas or have chronic health conditions (Table 2). Increased odds of missed visits to the GP was reported by females, those with disability/illness, with psychological distress or who are undergoing heart or asthma treatment (Table 2). Compared with unaffected participants, an over two-fold increase in negative (worse) impact on health due to missed or delayed access to care was reported by those with a disability or with high or very high psychological distress (Table 2).

Table 2.  Association between missed or delayed access to GP, specialist and dental health services by socio-demographic characteristics and health conditions.

Approximately half (48.0%) of the participants had used telehealth services since January 2020, including phone (96.0%) and video (9.0%). The highest rates, with > 1.5 increased odds of telehealth users, were among participants who had received treatment in the last month for cancer, mental health, heart disease and asthma (61.3%), those with a disability/illness and females (60.0%) (P < 0.05) (Table 3). A lower proportion of usage was found for males (43.2%), those aged 45–64 years (44.1%), from non-English-speaking backgrounds (41.8%) and residing in outer regional and remote areas (44.7%) (P < 0.05) (Table 3).

Table 3.  Use of telehealth services by socio-demographic characteristics.

Acceptability of telehealth services was reported to be ‘as good or better than in-person healthcare services’ by 59.7% of participants, although 30.2% reported the service was worse (Table 4). Two-thirds (67.7%) would recommend telehealth services to others and 82% indicated that telehealth would be useful post-pandemic. In contrast, 18% did not believe telehealth would be useful post-pandemic, particularly people aged 75+ years (25.7%), with a disability/illness (25.3%), ≤Year 12 education (24.6%), very high psychological distress (24.1%) or from the most disadvantaged areas (23.5%) (Table 4).

Table 4.  Experiences of people using telehealth services.

Our study found that the COVID-19 pandemic has had a considerable impact on access to healthcare services. Almost half the study population reported missed or delayed visits, particularly for dental, GP and specialist visits. Higher rates of missed health service visits were observed among females, those with a non-English-speaking background, and vulnerable groups including those with a disability/illness, elevated levels of psychological distress and chronic conditions. These groups were also more likely to report worse health during the COVID-19 pandemic, which may account for them being the highest users of telehealth. Telehealth services were accessed by half the study participants, with two-thirds finding it acceptable and 82% indicating it would be useful post-pandemic.

Our results are comparable to other studies reporting decreased access to healthcare services during the COVID-19 pandemic,^19,20 particularly decreased health visits to dentists, GPs and specialists, and primarily affecting those with chronic and mental health conditions. This is supported by a report by the Australian Institute of Health and Welfare (AIHW) that reported a decrease in emergency department presentations, mammogram screenings and Medicare-subsidised GP services for chronic disease management in the early months of the COVID-19 pandemic, but with a subsequent recovery of these services after 6–9 months.²¹ One study also noted a recovery of hospitalisations for chronic conditions following a substantial decrease in non-COVID-19 hospitalisations during the peak of the pandemic.²² However, investigation of the longer-term impact of reduced and delayed access to healthcare services on subsequent morbidity and mortality is required.

Regarding the impact on mental health, our findings are consistent with other studies that showed an increase in psychological distress as a result of the COVID-19 pandemic.^21,23 This is likely due to stressors associated with lockdown and public health restrictions, resulting in major uncertainty, impingement on personal freedom, financial losses, social and support service isolation, adapting to remote work situations and loneliness.^21,24,25 Further, our study found that a change in social contact was high, with 92% reporting reduced personal contact with others.

Telehealth has been identified as an important means of facilitating continued access to primary care services during the COVID-19 pandemic while minimising the community risk of transmission of COVID-19.^14,26 Although almost half of all participants used telehealth in our study, of importance is that the highest users were those with chronic conditions, high levels of psychological distress and a disability.

This may have been driven by the introduction of a temporary Medicare Benefits Schedule item to improve access to telehealth services.^27,28 Despite higher use of telehealth services among these groups, they reported worse health outcomes due to missed/delayed care. This suggests a population with a greater need for access to health care. Although at least half of the telehealth users in each health category found the service to be better or just as good as usual care, there was still one-third of participants who felt the service was worse than usual care. One qualitative study found that telehealth contributed to more isolation and disruption for some individuals, whereas others felt some conditions required a physical examination and were not suitable for telehealth.²⁵ A small South Australian study found that telehealth services were particularly useful for those with chronic conditions who did not require a physical examination, as the service enabled timely and convenient access to medications.²⁰ Identifying potential barriers to telehealth services that limited their use is important. A systematic review identified a number of factors to improve patient satisfaction using telehealth.²⁹ Knowledge of these factors could assist caregivers in targeting those highest at risk of decreased health outcomes and targeting specific telehealth modalities such a videoconferencing to address their needs adequately.

The strengths of this study are the large sample size of almost 50 000 respondents, providing contemporary and detailed self-reported information on health service access, health and wellbeing during the COVID-19 pandemic. However, a limitation is that the cohort primarily comprised NSW residents and people aged >45 years. Future studies including participants from across Australia, those aged <45 years and data linkage to administrative health data to quantify health service use would provide more representative and generalisable responses for the nation. Qualitative studies would also provide further insight into patient experiences of access to health services and impact on health.

The COVID-19 pandemic has impacted access to dental, GP and specialist health care, particularly among women, non-English speakers and vulnerable groups such as those with chronic illness, poor mental health and long-term disability. Vulnerable groups reported worse health and were most likely to access telehealth services. Understanding the widespread and far-reaching impacts of the COVID-19 pandemic, and identifying those who are most at risk, are crucial to inform the implementation of policy and health services that minimise adverse impacts on the community and ensure that they do not translate into persisting inequalities, or an exacerbation of existing inequalities and adverse health.

Supplementary material is available online.

The data that support this study were obtained from the SAX Institute by permission/licence. Data will be shared upon reasonable request to the corresponding author with permission from the SAX Institute.

The authors have no conflicts of interest to declare.

N. Nassar is supported by an Australian National Health and Medical Research Council (NHMRC) Leadership Investigator Grant (APP1197940).